'Yourself in all your forms': A grounded theory exploration of identity safety in medical students.

INTRODUCTION: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment. METHODS: This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations. RESULTS: Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment. DISCUSSION: Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

Trainees' perceptions of being allowed to fail in clinical training: A sense-making model.

INTRODUCTION: Clinical supervisors allow trainees to fail during clinical situations when trainee learning outweighs concerns for patient safety. Trainees perceive failure as both educationally valuable and emotionally draining; however, the nuance of supervised failures has not been researched from the trainee perspective. This study explored trainees' awareness and their experience of failure and allowed failure to understand those events in-depth. METHODS: We interviewed 15 postgraduate trainees from nine teaching sites in Europe and Canada. Participants were a purposive sample, representing 1-10 years of clinical training in various specialties. Consistent with constructivist grounded theory, data collection and analysis were iterative, supporting theoretical sampling to explore themes. RESULTS: Trainees reported that failure was a common, valuable, and emotional experience. They perceived that supervisors allowed failure, but they reported never having it explicitly confirmed or discussed. Therefore, trainees tried to make sense of these events on their own. If they interpreted a failure as allowed by the supervisor, trainees sought to ascertain supervisory intentions. They described situations where they judged supervisor's intentions to be constructive or destructive. DISCUSSION: Our results confirm that trainees perceive their failures as valuable learning opportunities. In the absence of explicit conversations with supervisors, trainees tried to make sense of failures themselves. When trainees judge that they have been allowed to fail, their interpretation of the event is coloured by their attribution of supervisor intentions. Perceived intentions might impact the educational benefit of the experience. In order to support trainees' sense-making, we suggest that supervisory conversations during and after failure events should use more explicit language to discuss failures and explain supervisory intentions.

Longitudinal exploration of students' identity formation during the transition from pre-clinical to clinical training using research poetry.

BACKGROUND: Transitions are critical periods that can lead to growth and, or, distress. Transitions are a sociocultural process, yet most approaches to transitions in practice and research do not explore the social or developmental aspects of entering a new training phase. Wenger reminds us that identity development is crucial when newcomers navigate change. In this paper, we use Wenger's modes of identification: engagement, imagination and alignment to explore students' identity development (as a student and professional) during the transition from pre-clinical to clinical training. METHODS: We enrolled nine 2nd-year medical students who generated 61 entries comprising audio diary (or typed) reflections over 9 months (starting 3 months before clinical clerkships began) and interviewed them twice. We used research poems (transcripts reframed as poetry) to help construct a meaningful, emotive elicitation of our longitudinal data and analysed data using sensitising concepts from Wenger's modes of identification. RESULTS: Students described their transition as a journey filled with positive and negative emotions and uncertainty about their current and future careers. Students navigated the transition using three mechanisms: (1) becoming more engaged through taking charge, (2) shaping their image of self through engagement and finding role models and (3) learning to flexibly adapt to clerkship norms by managing expectations and adopting a journey mindset. CONCLUSIONS: We successfully narrated students' identity formation during their transition to clinical training. We learned that students became more engaged over time by learning to take charge. They shaped their image of self by engaging in team activities and reflecting on role models. They learnt to adapt flexibly to clerkship norms by managing expectations and adopting a journey mindset. We suggest that institutions provide a safe opportunity for medical students to reflect, allowing students' transition periods to be lived, reflected on and supported.

A phenomenology of direct observation in residency: Is Miller's 'does' level observable?

INTRODUCTION: Guidelines on direct observation (DO) present DO as an assessment of Miller's 'does' level, that is, the learner's ability to function independently in clinical situations. The literature, however, indicates that residents may behave 'inauthentically' when observed. To minimise this 'observer effect', learners are encouraged to 'do what they would normally do' so that they can receive feedback on their actual work behaviour. Recent phenomenological research on patients' experiences with DO challenges this approach; patients needed-and caused-some participation of the observing supervisor. Although guidelines advise supervisors to minimise their presence, we are poorly informed on how some deliberate supervisor participation affects residents' experience in DO situations. Therefore, we investigated what residents essentially experienced in DO situations. METHODS: We performed an interpretive phenomenological interview study, including six general practice (GP) residents. We collected and analysed our data, using the four phenomenological lenses of lived body, lived space, lived time and lived relationship. We grouped our open codes by interpreting what they revealed about common structures of residents' pre-reflective experiences. RESULTS: Residents experienced the observing supervisor not just as an observer or assessor. They also experienced them as both a senior colleague and as the patient's familiar GP, which led to many additional interactions. When residents tried to act as if the supervisor was not there, they could feel insecure and handicapped because the supervisor was there, changing the situation. DISCUSSION: Our results indicate that the 'observer effect' is much more material than was previously understood. Consequently, observing residents' 'authentic' behaviour at Miller's 'does' level, as if the supervisor was not there, seems impossible and a misleading concept: misleading, because it may frustrate residents and cause supervisors to neglect patients' and residents' needs in DO situations. We suggest that one-way DO is better replaced by bi-directional DO in working-and-learning-together sessions.

Training infectious diseases senior residents during COVID-19: The impact and the lessons learnt.

BACKGROUND: The COVID-19 pandemic had major impact on the training of Infectious Diseases (ID) residents across the globe. They were part of the frontline staff, while at the same time training to be ID physicians. This study focused on identifying their capability, i.e. the ability to adapt existing competencies to new situations, which is now recognised as an essential element of professional practice. AIM: This study explored what ID residents learnt and how they learnt as they adapted to working in this unpredictable and challenging COVID-19 pandemic. METHODS: This qualitative explorative study was based in the Infectious Diseases Senior Residency Programme across three training institutions in Singapore. Individual semi-structured interviews were conducted. Data were analysed using a template analysis technique. RESULTS: Nine ID residents participated in this study. They learnt to engage with uncertainty in a meaningful way by relying on prior training and rapidly learning how to most effectively learn (metacognition). Learning was enhanced by collaboration between multidisciplinary health professionals, strong leadership and intrinsic motivation from personal interest in ID. They learnt through observing how senior faculty approached and managed the COVID-19 situation. CONCLUSION: When learning for future capability in a rapidly evolving situation, role-modelling and mentoring are essential as available information resources may still not provide the learning from skilled doctors with actual experiences managing complex, uncertain situations.

Challenges, coping and support during student placement abroad: A qualitative study.

BACKGROUND: During placements abroad, healthcare students are confronted with different personal and professional challenges, related to participation in practice. This study investigates when and how students respond to such challenges, and which coping and support mechanisms students use to overcome these. METHODS: Twenty-five international students shared their experiences about physiotherapy placement in The Netherlands. Using a critical incident technique, we asked participants to recall events where participation was affected by an unforeseen situation, in or outside the clinic. Further, we explored students' strategies of seeking support within their social network to overcome individual challenges. Two researchers applied thematic analysis to the interview data, following an iterative approach. Team discussions supported focused direction of data collection and analysis, before conceptualizing results. RESULTS: Participants described a wide range of challenges. The scope and impact level of challenges varied widely, including intercultural differences, language barriers and inappropriate behaviour in the workplace, students' personal context and wellbeing. Mechanisms employed by students to overcome these challenges depended on the type of event (personal or professional), making purposeful use of their available network. CONCLUSION: Students involve clinical staff, peers, family and friends during placement abroad, to make deliberate use of their support network to overcome challenges in participation, whereas the academic network remains distant. Findings may help reflect on the roles and responsibilities of academic staff and other professionals involved with placements abroad. Healthcare programmes should ensure support before, during and after placement is within students' reach.

Pharmacist trainees narrow scope of interprofessional collaboration and communication in hospital practice.

Early curricular exposure to interprofessional education (IPE) is intended to acclimatize health professional trainees to shared-care in the practice settings they will ultimately join. However, IPE activities typically reside outside actual organizational and social systems in which interprofessional care is delivered. We aimed to explore how pharmacist trainees experience collaborator and communicator competency roles during team-based workplace-based learning. Participants maintained written diaries reflecting on interprofessional collaboration and communication during an eight-week hospital clerkship. Diary entries and transcripts from semi-structured follow-up interviews were analyzed from the social constructivist perspective using reflective thematic analysis. Participant accounts of on-ward activities represented most collaborator and communicator roles outlined in pharmacy and interprofessional competency frameworks, but were predominantly between the pharmacist trainee and physicians. Pharmacist trainees did not routinely engage with other health professions on a daily basis. Additionally, reported encounters with other team members were typically information exchanges and not episodes of authentic interdependent or shared care. Interactions were almost completely devoid of perceived interpersonal or role conflict. These findings offer insight into how pharmacist trainees perceive and develop competencies for team-based care. Further work is required to understand how such limited scope of interprofessional communication and collaboration might ultimately impair quality patient care.

Assessing trainee performance: ensuring learner control, supporting development, and maximizing assessment moments.

In this article, the authors provide practical guidance for frontline supervisors' efforts to assess trainee performance. They focus on three areas. First, they argue the importance of promoting learner control in the assessment process, noting that providing learners agency and control can shift the stakes of assessment from high to low and promote a safe environment that facilitates learning. Second, they posit that assessment should be used to support continued development by promoting a relational partnership between trainees and supervisors. This partnership allows supervisors to reinforce desirable aspects of performance, provide real-time support for deficient areas of performance, and sequence learning with the appropriate amount of scaffolding to push trainees from competence (what they can do alone) to capability (what they are able to do with support). Finally, they advocate the importance of optimizing the use of written comments and direct observation while also recognizing that performance is interdependent in efforts to maximize assessment moments.Conclusion: Using best practices in trainee assessment can help trainees take next steps in their development in a learner-centered partnership with clinical supervisors. What is Known: • Many pediatricians are asked to assess the performance of medical students and residents they work with but few have received formal training in assessment. What is New: • This article presents evidence-based best practices for assessing trainees, including giving trainees agency in the assessment process and focusing on helping trainees take next steps in their development.

Strangers in a strange land: The experience of physicians undergoing remediation.

INTRODUCTION: The experience of remediation in practising physicians has not been widely studied. Remediatees frequently present negative emotions, but observers can only infer the underlying reasons behind these. Understanding remediatees' perspectives may help those mandating and organising remediation to structure the process in ways that improve the experience for all concerned parties and maximise chances of a successful outcome for remediatees. METHODS: Seventeen physicians who had undergone remediation for clinical competence concerns were interviewed via telephone. Participant data were first iteratively analysed thematically and then reanalysed using a narrative mode of analysis for each participant in order to understand the stories as wholes. Figured worlds (FW) theory was used as a lens for analysing the data for this constructivist research study. RESULTS: Participants entering the FW of remediation perceived that their position as a 'good doctor' was threatened. Lacking experience with this world and with little available support to help them navigate it, participants used their agency to draw on various discursive threads within the FW to construct a narrative account of their remediation. In their narratives, participants tended to position themselves either as victims of regulatory bodies or as resilient individuals who could make the best of a difficult situation. In both cases, the chosen discursive threads enabled them to maintain their self-identity as 'good doctor'. CONCLUSION: Remediation poses a threat to a physician's professional and personal identity. Focusing mainly on the educational aspect of remediation-that is, the improvement in knowledge and skills-risks missing its impact on physician identity. We need to ensure not only that we support physicians in dealing with this identity threat but that our assessment and remediation processes do not inadvertently encourage remediatees to draw on discursive threads that lead them to see themselves as victims.

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

PURPOSE: Clinical supervisors acknowledge that they sometimes allow trainees to fail for educational purposes. What remains unknown is how supervisors decide whether to allow failure in a specific instance. Given the high stakes nature of these decisions, such knowledge is necessary to inform conversations about this educationally powerful and clinically delicate phenomenon. MATERIALS AND METHODS: 19 supervisors participated in semi-structured interviews to explore how they view their decision to allow failure in clinical training. Following constructivist grounded theory methodology, the iteratively collected data and analysis were informed by theoretical sampling. RESULTS: Recalling instances when they considered allowing residents to fail for educational purposes, supervisors characterized these as intuitive, in-the-moment decisions. In their post hoc reflections, they could articulate four factors that they believed influenced these decisions: patient, supervisor, trainee, and environmental factors. While patient factors were reported as primary, the factors appear to interact in dynamic and nonlinear ways, such that supervisory decisions about allowing failure may not be predictable from one situation to the next. CONCLUSIONS: Clinical supervisors make many decisions in the moment, and allowing resident failure appears to be one of them. Upon reflection, supervisors understand their decisions to be shaped by recurring factors in the clinical training environment. The complex interplay among these factors renders predicting such decisions difficult, if not impossible. However, having a language for these dynamic factors can support clinical educators to have meaningful discussions about this high-stakes educational strategy.

Why impaired wellness may be inevitable in medicine, and why that may not be a bad thing.

CONTEXT: A wellness crisis exists among physicians and medical trainees. High rates of burnout, depression, stress and other states of impaired wellness have driven a sense of urgency to create solutions, and the medical education community has mobilised impressively. However, we argue-and data suggest-that this rush to find solutions has outpaced our efforts to more fully understand the nature of impaired wellness in medicine. This, we believe, has led to the implementation of solutions informed by limited understanding of the problems we intend to solve. METHODS: In this paper, we explore three contributors to this situation: (i) shaky definitions and conceptualisations of wellness, (ii) the predominance of deductive, quantitative research informing our understanding and current solutions, and (iii) the reliance on a 'disease-focused' approach to addressing impaired wellness in physicians and trainees. We discuss how these contributors have led to the current state of the science of wellness in medicine: one characterised by an expanding array of solutions built upon narrow conceptualisations of wellness and how it can be impaired. DISCUSSION: Moving beyond the current state of the science on wellness in medicine will require three critical developments: (i) consistent use of clear definitions of wellness; (ii) expanding our methodologies to include those utilising direct interaction with participants; and (iii) moving beyond solutions informed by a disease-model approach. We propose a different way of thinking about wellness: one based on what we view as an inherent-and potentially unavoidable-risk of experiencing impairment during a career in medicine. We argue that efforts to extinguish and eliminate all states of impaired wellness may also eliminate opportunities to develop constructive coping mechanisms and future resilience, and that wellness may best be conceptualised as healthy and authentic engagement with the inevitable adversity of a career in medicine.

Longitudinal qualitative research in medical education: Time to conceptualise time.

CONTEXT: Longitudinal qualitative research is an approach to research that entails generating qualitative data with the same participants over extended periods of time to understand their lived experiences as those experiences unfold. Knowing about dynamic lived experiences in medical education, that is, learning journeys with stops and starts, detours, transitions and reversals, enriches understanding of events and accomplishments along the way. The purpose of this paper is to create access points to longitudinal qualitative research in support of increasing its use in medical education. METHODS: The authors explore and argue for different conceptualisations of time: analysing lived experiences through time versus analysing lived experiences cross-sectional or via 2-point follow-up studies and considering time as subjective and fluid as well as objective and fixed. They introduce applications of longitudinal qualitative research from several academic domains: investigating development and formal education; building longitudinal research relationship; and exploring interconnections between individual journeys and social structures. They provide an illustrative overview of longitudinal qualitative research in medical education, and end with practical advice, or pearls, for medical education investigators interested in using this research approach: collecting data recursively; analysing longitudinal data in three strands; addressing mutual reflexivity; using theory to illuminate time; and making a long-term commitment to longitudinal qualitative research. CONCLUSIONS: Longitudinal qualitative research stretches investigators to think differently about time and undertake more complex analyses to understand dynamic lived experiences. Research in medical education will likely be impoverished if the focus remains on time as fixed. Seeing things qualitatively through time, where time is fluid and the past, present and future interpenetrate, produces a rich understanding that can move the field forward.

'I'm unworthy of being in this space': The origins of shame in medical students.

OBJECTIVES: Shame results from a negative global self-evaluation and can have devastating effects. Shame research has focused primarily on graduate medical education, yet medical students are also susceptible to its occurrence and negative effects. This study explores the development of shame in medical students by asking: how does shame originate in medical students? and what events trigger and factors influence the development of shame in medical students? METHODS: The study was conducted using hermeneutic phenomenology, which seeks to describe a phenomenon, convey its meaning and examine the contextual factors that influence it. Data were collected via a written reflection, semi-structured interview and debriefing session. It was analysed in accordance with Ajjawi and Higgs' six steps of hermeneutic analysis: immersion, understanding, abstraction, synthesis, illumination and integration. RESULTS: Data analysis yielded structural elements of students' shame experiences that were conceptualised through the metaphor of fire. Shame triggers were the specific events that sparked shame reactions, including interpersonal interactions (eg, receiving mistreatment) and learning (eg, low test scores). Shame promoters were the factors and characteristics that fuelled shame reactions, including those related to the individual (eg, underrepresentation), environment (eg, institutional expectations) and person-environment interaction (eg, comparisons to others). The authors present three illustrative narratives to depict how these elements can interact to lead to shame in medical students. CONCLUSIONS: This qualitative examination of shame in medical students reveals complex, deep-seated aspects of medical students' emotional reactions as they navigate the learning environment. The authors posit that medical training environments may be combustible, or possessing inherent risk, for shame. Educators, leaders and institutions can mitigate this risk and contain damaging shame reactions by (a) instilling a true sense of belonging and inclusivity in medical learning environments, (b) facilitating growth mindsets in medical trainees and (c) eliminating intentional shaming in medical education.

Students' social networks are diverse, dynamic and deliberate when transitioning to clinical training.

CONTEXT: Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre-clinical to clinical training. METHODS: Eight medical students completed a social network map during a semi-structured interview within two weeks of beginning their clinical clerkships (T0 ) and then again four months later (T1 ). They indicated meaningful interactions that influenced their transition from pre-clinical to clinical training and discussed how these relationshipsimpacted their transition. We conducted mixed-methods analysis on this data. RESULTS: At T0 , eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T1 . People from within and beyond the clinical space made up participants' social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near-peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance). CONCLUSIONS: This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students' social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions.

Skeptical self-regulation: Resident experiences of uncertainty about uncertainty.

OBJECTIVES: Managing uncertainty is central to expert practice, yet how novice trainees navigate these moments is likely different than what has been described by experienced clinicians. Exploring trainees' experiences with uncertainty could therefore help explicate the unique cues that they attend to, how they appraise their comfort in these moments and how they enact responses within the affordances of their training environment. METHODS: Informed by constructivist grounded theory, we explored how novice emergency medicine trainees experienced and managed clinical uncertainty in practice. We used a critical incident technique to prompt participants to reflect on experiences with uncertainty immediately following a clinical shift, exploring the cues they attended to and the approaches they used to navigate these moments. Two investigators coded line-by-line using constant comparison, organising the data into focused codes. The research team discussed the relationships between these codes and developed a set of themes that supported our efforts to theorise about the phenomenon. RESULTS: We enrolled 13 trainees in their first two years of postgraduate training across two institutions. They expressed uncertainty about the root causes of the patient problems they were facing and the potential management steps to take, but also expressed a pervasive sense of uncertainty about their own abilities and their appraisals of the situation. This, in turn, led to challenges with selecting, interpreting and using the cues in their environment effectively. Participants invoked several approaches to combat this sense of uncertainty about themselves, rehearsing steps before a clinical encounter, checking their interpretations with others and implicitly calibrating their appraisals to those of more experienced team members. CONCLUSIONS: Trainees' struggles with the legitimacy of their interpretations impact their experiences with uncertainty. Recognising these ongoing struggles may enable supervisors and other team members to provide more effective scaffolding, validation and calibration of clinical judgments and patient management.

Warning bells: How clinicians leverage their discomfort to manage moments of uncertainty.

OBJECTIVES: It remains unclear how medical educators can more effectively bridge the gap between trainees' intolerance of uncertainty and the tolerance that experienced physicians demonstrate in practice. Exploring how experienced clinicians experience, appraise and respond to discomfort arising from uncertainty could provide new insights regarding the kinds of behaviours we are trying to help trainees achieve. METHODS: We used a constructivist grounded theory approach to explore how emergency medicine faculty experienced, managed and responded to discomfort in settings of uncertainty. Using a critical incident technique, we asked participants to describe case-based experiences of uncertainty immediately following a clinical shift. We used probing questions to explore cognitive, emotional and somatic manifestations of discomfort, how participants had appraised and responded to these cues, and how they had used available resources to act in these moments of uncertainty. Two investigators coded the data line by line using constant comparative analysis and organised transcripts into focused codes. The entire research team discussed relationships between codes and categories, and developed a conceptual framework that reflected the possible relationships between themes. RESULTS: Participants identified varying levels of discomfort in their case descriptions. They described multiple cues alerting them to problems that were evolving in unexpected ways or problems with aspects of management that were beyond their abilities. Discomfort served as a trigger for participants to monitor a situation with greater attention and to proceed more intentionally. It also served as a prompt for participants to think deliberately about the types of human and material resources they might call upon strategically to manage these uncertain situations. CONCLUSIONS: Discomfort served as a dynamic means to manage and respond to uncertainty. To be 'tolerant' of uncertainty thus requires clinicians to embrace discomfort as a powerful tool with which to grapple with the complex problems pervasive in clinical practice.

Contextual Competence: How residents develop competent performance in new settings.

INTRODUCTION: Medical education continues to diversify its settings. For postgraduate trainees, moving across diverse settings, especially community-based rotations, can be challenging personally and professionally. Competent performance is embedded in context; as a result, trainees who move to new contexts are challenged to use their knowledge, skills and experience to adjust. What trainees need to adapt to and what that requires of them are poorly understood. This research takes a capability approach to understand how trainees entering a new setting develop awareness of specific contextual changes that they need to navigate and learn from. METHODS: We used constructivist grounded theory with in-depth interviews. A total of 29 trainees and recent graduates from three internal medicine training programmes in Canada participated. All participants had completed at least one community-based rotation geographically far from their home training site. Interviews were recorded, transcribed and anonymised. The interview framework was adjusted several times following initial data analysis. RESULTS: Contextual competence results from trainees' ability to attend to five key stages. Participants had first to meet their physiological and practical needs, followed by developing a sense of belonging and legitimacy, which paved the way for a re-constitution of competence and appropriate autonomy. Trainee's attention to these stages of adaptation was facilitated by a process of continuously moving between using their knowledge and skill foundation and recognising where and when contextual differences required new learning and adaptations. DISCUSSION: An ability to recognise contextual change and adapt accordingly is part of Nussbaum and Sen's concept of capability development. We argue this key skill has not received the attention it deserves in current training models and in the support postgraduate trainees receive in practice. Recommendations include supporting residents in their capability development by debriefing their experiences of moving between settings and supporting clinical teachers as they actively coach residents through this process.

A phenomenological investigation of patients' experiences during direct observation in residency: busting the myth of the fly on the wall.

Direct observation (DO) of residents by supervisors is a highly recommended educational tool in postgraduate medical education, yet its uptake is poor. Residents and supervisors report various reasons for not engaging in DO. Some of these relate to their interaction with patients during DO. We do not know the patient perspectives on these interactions, nor, more broadly, what it is like to be a patient in a DO situation. Understanding the patient perspective may lead to a more complete understanding of the dynamics in DO situations, which may benefit patient wellbeing and improve the use of DO as an educational tool. We conducted a phenomenological interview study to investigate the experience of being a patient in a DO situation. Our analysis included multiple rounds of coding and identifying themes, and a final phase of phenomenological reduction to arrive at the essential elements of the experience. Constant reflexivity was at the heart of this process. Our results provide a new perspective on the role of the supervisor in DO situations. Patients were willing to address the resident, but sought moments of contact with, and some participation by, the supervisor. Consequently, conceptions of DO in which the supervisor thinks she is a fly on the wall rather than a part of the interaction, should be critically reviewed. To that end, we propose the concept of participative direct observation in workplace learning, which also acknowledges the observer's role as participant. Embracing this concept may benefit both patients' wellbeing and residents' learning.

Leadership in interprofessional healthcare teams: Empowering knotworking with followership.

Healthcare professionals need to be able to collaborate in interprofessional healthcare teams (IHTs). This paper discusses how healthcare professionals (can) contribute to IHT effectiveness. Using cultural historical activity theory and its affiliated concept of knotworking, it argues that healthcare professionals would benefit from developing not just leadership but also followership skills. Moreover, IHT collaborators need the ability to switch fluently between leader and follower roles as appropriate to advance patient care. This fluency is essential for collaborative knotworking. Knotworking refers to the process of tying and retying together individual threads of activity and expertise from across the IHT, over time, to achieve specific objects. Knotworking highlights the dynamic dimensions of IHT collaboration that require professionals to be both effective leaders and followers. The perspectives presented in this paper lead to a different view of IHTs, one that recognizes how leaders and followers co-produce the leadership teams need.

Team member expectations of trainee communicator and collaborator competencies - so shines a good deed in a weary world?

BACKGROUND: Workplace-based assessment may be further optimized by drawing upon the perspectives of multiple assessors, including those outside the trainee's discipline. Interprofessional competencies like communication and collaboration are often considered suitable for team input. AIM: We sought to characterize multidisciplinary expectations of communicator and collaborator competency roles. METHODS: We adopted a constructivist grounded theory approach to explore perspectives of multidisciplinary team members on a clinical teaching unit. In semi-structured interviews, participants described expectations for competent collaboration and communication of trainees outside their own discipline. Data were analyzed to identify recurring themes, underlying concepts and their interactions using constant comparison. RESULTS: Three main underlying perspectives influenced interprofessional characterization of competent communication and collaboration: (1) general expectations of best practice; (2) specific expectations of supportive practice; and (3) perceived commitment to teaching practice. However, participants seemingly judged trainees outside their discipline according to how competencies were exercised to advance their own professional patient care decision-making, with minimal attention to the trainee's specific skillset demonstrated. CONCLUSION: While team members expressed commitment to supporting interprofessional competency development of trainees outside their discipline, service-oriented judgement of performance loomed large. The potential impact on the credibility of multidisciplinary sources for workplace-based assessment requires consideration.